Integrated Control of Neglected Zoonotic Diseases in Africa

Integrated Control of Neglected Zoonotic Diseases in Africa Applying the One Health Concept Report of a Joint WHO/EU/ILRI/DBL/FAO/OIE/AU Meeting ILRI Headquarters, Nairobi, 13 15 November 2007

Photo cover: Elisabeth Specht

WHO/HTM/NTD/NZD/2008.1 Integrated Control of Neglected Zoonotic Diseases in Africa Applying the One Health Concept Report of a Joint WHO/EU/ILRI/DBL/FAO/OIE/AU Meeting ILRI headquarters, Nairobi, Kenya 13 15 November 2007 Zoonoses and Veterinary Public Health Department of Food Safety, Zoonoses, and Foodborne Diseases Sustainable Development and Healthy Environments http://www.who.int/neglected_diseases/zoonoses/en/

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Integrated Control of Neglected Zoonotic Diseases in Africa Preface Endemic zoonotic diseases such as anthrax, bovine tuberculosis, brucellosis, cysticercosis, echinococcosis (hydatid disease), rabies and zoonotic trypanosomiasis (sleeping sickness) occur throughout the African continent where conditions for their maintenance and spread exist. These diseases perpetuate poverty by attacking not only people s health but also their livelihoods. Unfortunately, these persistent zoonoses remain neglected in most of the African countries where they are endemic because of lack of information and awareness about the extent of the problem, lack of suitable diagnostic and managerial capacity, and lack of appropriate and sustainable strategies for prevention and control. The result is a false perception that the burden of these diseases and their impact on society are low, such that they neither attract the health resources nor the research needed for their control effectively putting them in the category of neglected zoonotic diseases (NZDs). Control of NZDs, by simultaneously saving lives and securing livelihoods, offers a very real and highly cost-effective opportunity for alleviating poverty, especially in remote rural areas and marginalized periurban communities. In many African countries, the veterinary public health infrastructure is poor or nonexistent, generating indecision as to which sector(s) should take responsibility for investigating and controlling NZDs (the veterinary or agricultural sector versus the health sector). This situation has led to control of NZDs falling into the gap between veterinary responsibilities and medical needs. Because NZDs affect both humans and animals, especially where they involve livestock, interventions to control NZDs require concerted action between veterinary, livestock and human health sectors. A comprehensive, interdisciplinary approach is therefore needed to address the major obstacles to control NZDs. This joint meeting brought together researchers, those working on the control of NZDs and policy-makers from across the African continent to discuss and plan the specific actions needed to implement a regional programme for understanding and controlling NZDs. These actions are detailed in the proceedings of the meeting contained in this report. The results of such a programme will benefit the many communities affected by these diseases. Successful control of NZDs entails effective leadership and concerted effort as well as technical, financial and political support. The NZD initiative is focusing first on Africa as the continent most affected by these diseases. Together, we should seize the opportunity afforded to make a genuine difference. The representatives of WHO, EU, ILRI, DBL, FAO, OIE and AU ii ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept Acknowledgements The organizers of the meeting would like to express their sincere thanks to all those who contributed to its success especially to the participants for their valuable inputs during the plenary and working group sessions. Particular gratitude is due to Dr Malika Kachani and Dr Sayoki Mfinanga for chairing and co-chairing the meeting, respectively, and to Dr Eric Fèvre and Professor James Mlangwa for serving as rapporteurs. These individuals also provided invaluable assistance by leading and reporting on the discussions and recommendations of the working groups. The meeting would not have been possible without the excellent day-to-day organization provided by Marion Reverdin at WHO headquarters, by Albert Minyangadou Ngokobi and other staff at the WHO Kenya Country Office in Nairobi, and by Gertrude Ngeleshi, Veyrl Adell, Vivian Awuor and the many other support staff at ILRI. Special thanks go to Dr Alexandra Shaw for suggesting a timely follow-up to the first NZD meeting. Dr François Meslin, WHO headquarters, convenor of the meeting was assisted by Dr Arve Lee Willingham of the WHO/FAO Collaborating Center for Parasitic Zoonoses at the University of Copenhagen in Denmark with regards to the overall coordination and reporting of the meeting on behalf of the organizing agencies. ILRI, Nairobi, 13 15 November 2007 iii

Integrated Control of Neglected Zoonotic Diseases in Africa Summary Control of neglected zoonotic diseases (NZDs), by simultaneously saving lives and securing livelihoods, offers an important opportunity for alleviating poverty in remote rural areas and among marginalized periurban communities of poor livestock keepers in Africa and other less developed areas of the world. The meeting held at the headquarters of the International Livestock Research Institute (ILRI) in Nairobi, Kenya during 13 15 November 2007 was supported jointly by the World Health Organization (WHO), the European Commission (EU), ILRI, the DBL-Centre for Health Research and Development (DBL), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the African Union (AU). It focused on the need to and opportunities for combating NZDs in Africa as the most affected continent where all of the NZDs occur; and where their burden on society hinders development and has a serious impact on health and agriculture. The objective of the meeting was to formulate a strategic framework for implementing the action points for combating NZDs that arose from an initial meeting held at WHO in 2005. 1 These actions were to promote a one health integrated approach to control of NZDs, to develop plans for advocacy and information, to improve diagnosis and surveillance, to foster research, to build capacity and to strengthen prevention and control activities. A multidisciplinary group of researchers, programme managers and policy-makers from across the African continent was brought together with international experts and representatives of regional and international technical support agencies and organizations to address practical, institutional, political and resource-related issues associated with integrated surveillance, prevention and control of NZDs in Africa. The meeting appreciated that controlling, preventing and eventually eliminating NZDs would be highly cost effective from a societal point of view, taking into account both the health and agricultural aspects. A plan of action for implementing integrated control of NZDs in Africa is recommended as follows. To provide global and regional leadership to promote and coordinate the one health integrated approach to control of NZDs through the establishment of an International Scientific Advisory Committee (ISAC) for NZDs. To promote advocacy efforts to inform about the societal burden of NZDs to create demand for their control. To conduct, maintain and report inventories of control activities and tools. To develop and test practical, cost-effective strategies for surveillance and control. To produce guidelines for implementing surveillance, prevention and control activities. 1 www.who.int/zoonoses/report_sept06.pdf iv ILRI, Nairobi, 13 15 November 2007

Integrated Control of Neglected Zoonotic Diseases in Africa Contents Preface -----------------------------------------------------------------------------ii Acknowledgements -------------------------------------------------------------iii Summary ------------------------------------------------------------------------- iv Contents --------------------------------------------------------------------------- vi 1. Introduction ---------------------------------------------------------------1 2. Background ---------------------------------------------------------------2 3. Objectives ------------------------------------------------------------------4 4. Conclusions ---------------------------------------------------------------6 5. Recommendations -------------------------------------------------------7 6. Management and advocacy ------------------------------------------ 10 7. Research and capacity building ------------------------------------- 17 8. Diagnostics and surveillance ----------------------------------------- 22 9. Prevention and control ------------------------------------------------ 26 Abstracts of plenary presentations ----------------------------------------- 30 Abbreviations ------------------------------------------------------------------- 40 References ----------------------------------------------------------------------- 42 Agenda --------------------------------------------------------------------------- 43 List of participants ------------------------------------------------------------- 45 vi ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept 1 Introduction A joint meeting on integrated control of neglected zoonotic diseases in Africa was organized in Nairobi, Kenya from 13 to 15 November 2007 by the World Health Organization (WHO) in collaboration with the European Commission (EU), the International Livestock Research Institute (ILRI), the DBL-Centre for Health Research and Development (DBL), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the African Union (AU). The meeting was opened by Dr Carlos Seré, Director-General, ILRI; Dr Abdoulaye Diarra representing the WHO Regional Office for Africa (AFRO); Dr William Amanfu representing FAO; Dr Nicolas Denormandie representing OIE; Dr Isabel Minguez-Tudela representing the EU s Research Directorate, Dr Maria Vang Johansen representing DBL and Dr Hameed Nuru representing the African Union s InterAfrican Bureau for Animal Resources (AU-IBAR). Dr François Meslin, Coordinator, Zoonoses and Veterinary Public Health, welcomed participants on behalf of WHO headquarters and, assisted by Dr Lee Willingham, presented the background, objective and agenda of the meeting. Participants elected Dr Malika Kachani, of the Western University of Health Sciences College of Veterinary Medicine (USA) as Chairperson and Dr Sayoki Mfinanga of the Muhimbili Research Centre, National Institute of Medical Research (United Republic of Tanzania) as Co-Chairperson. Dr Eric Fèvre of the University of Edinburgh s Centre for Infectious Diseases (Scotland) was elected as Rapporteur and Professor James Mlangwa of the Department of Veterinary Medicine and Public Health, Faculty of Veterinary Medicine, Sokoine University of Agriculture (United Republic of Tanzania) was elected as Co-Rapporteur. Participants at the meeting on Integrated Control of Neglected Zoonotic Diseases in Africa held at ILRI headquarters in Nairobi, Kenya ILRI ILRI, Nairobi, 13 15 November 2007 1

Integrated Control of Neglected Zoonotic Diseases in Africa 2 Background Proceedings of the WHO/DFID-AHP meeting The control of neglected zoonotic diseases: a route to poverty alleviation can be obtained freely via the Internet: www.who.int/zoonoses/report_sept06.pdf Promote the concept of one health by dealing with health problems in both people, their livestock and other domestic and wild animals they depend on through the development of integrated control packages that address several disease/ health problems WHO/DFID-AHP Control of Neglected Zoonotic Diseases Meeting, 2005 Although many meetings and initiatives have addressed emerging and re-emerging diseases, the particular focus on endemic zoonoses and the problems of their control has been lacking. There is increasing interest in neglected zoonotic diseases (NZDs), an under-diagnosed group of diseases whose neglect stems from various reasons, including the fact that the main burden of these diseases falls mostly on poor and marginalized populations. There is today a growing body of evidence to suggest that many of these diseases impact negatively on livestock productivity, undermining livelihoods both by causing illness in the household and by threatening its livestock and their output. Many of these diseases are more or less effectively controlled in industrialized countries, but are emerging or re-emerging in developing countries, particularly in Africa. Since controlling them is highly cost effective from a societal point of view, taking into account both the health and the agricultural aspects, this is an area where interventions have enormous potential to alleviate poverty. An international meeting jointly organized by the UK s Department for International Development-Animal Health Programme (DFID-AHP) and the World Health Organization (WHO) was held at WHO s headquarters in Geneva, Switzerland in September 2005, entitled The control of neglected zoonotic diseases: a route to poverty alleviation to focus international attention on the issue. Seven endemic zoonoses, namely anthrax, bovine tuberculosis, brucellosis, cysticercosis, echinococcosis, rabies and zoonotic trypanosomiasis, were targeted as the initial group of NZDs at which to direct concerted efforts. The report of this first meeting outlined the needs, justification and opportunities for combating NZDs and proposed five main action points to accomplish this: to promote a one health integrated approach, to develop plans for advocacy and information, to improve diagnosis and surveillance, to foster research, and to strengthen prevention and control activities. This second meeting addressed the needs and opportunities for controlling NZDs in Africa, which is the continent most affected by NZDs, where these diseases are endemic and where their combined burden seriously hinders development. The objective of the meeting was to formulate a strategic framework for implementing the action points emanating from the first meeting. The involvement of researchers, programme managers and policymakers in this planning phase was to enable the intended outcome of the meeting effective and sustainable control of NZDs in Africa. 2 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept Distribution of selected zoonotic diseases No data available 1 disease reported 2 diseases reported 3 diseases reported >3 diseases reported World Health Organization 2005 All rights reserved. Overlap of 5 selected neglected zoonotic diseases at country level in Africa: cutaneous leishmaniasis (anthroponotic and zoonotic), zoonotic trypanosomiasis, echinococcosis, cysticercosis (Taenia solium) and rabies. No attempt has been made to differentiate diseases that occur focally within each country. Over 30% of African countries have 3 or more of these NZDs in various combinations. Note that the boundaries shown and the designation used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country territory, city or areas or its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Data source: World Health Organization map production: Public Health Information and Geographical Information Systems (GIS) World Health Organization. ILRI, Nairobi, 13 15 November 2007 3

Integrated Control of Neglected Zoonotic Diseases in Africa 3 Objectives The objective of the meeting was to address the practical, institutional, political and resource-related issues associated with integrated surveillance, prevention and control of NZDs on the African continent by formulating a specific implementation plan for accomplishing the action points emanating from the first meeting on NZDs held in 2005 (see Table). A multidisciplinary group of researchers, programme managers and policy-makers from across the African continent was brought together with international experts and representatives of regional and international technical support agencies and organizations to develop this strategic framework for implementation. The meeting was arranged such that researchers and programme managers first came together to discuss the situation of NZDs in Africa and to consider in-depth through working groups specific realistic actions at the regional and national levels that could be undertaken to effectively and sustainably relieve the burden of NZDs. Four working groups were convened to cover the areas that needed to be addressed: management and advocacy research and training (changed to research and capacity building) diagnostics and surveillance prevention and control. On the third day of the meeting, regional policy-makers were informed about the needs and opportunities for combating NZDs and invited to provide feedback on how the issue and actions to address it (i.e. integrated surveillance and control) would be considered from their viewpoint and to make suggestions for refinement. The outcome was an appropriate and achievable plan of action for each of the thematic areas. The key issues considered, main discussion points and action plans developed by each of the working groups, which are presented below. In support of the working groups deliberations, plenary presentations were provided by key speakers on topics of relevance. Two keynote presentations were given on the one health approach to prevention and control of NZDs and the double benefits of the control of NZDs in consideration of their dual burden on health and agriculture, respectively. Other presentations on trends, initiatives, programmes and approaches of relevance to NZD surveillance and control in Africa included: Changes in livestock marketing and production systems in Africa Avian influenza: paving the way for surveillance and control of NZDs The intersectoral approach to sleeping sickness control Challenges and opportunities for integrated control of NZDs OIE s information system (WAHIS) and database (WAHID) The EU s FP7 for research and the ETPGAH The Global Alliance for Livestock Veterinary Medicines (GALVmed) The health promotion approach for control of NZDs. Abstracts of these presentations are included in the proceedings (pages 30 39). 4 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept The five action points from the initial meeting of control of NZDs in 2005 Action Points Activities Needed 1/ Promote One Health Veterinary and medical aspects of NZDs control must be linked at all levels approach to integrated thereby promoting and facilitating communication, cooperation and surveillance and control of NZDs collaboration across sectors and disciplines 2/ Advocacy and Information Establish a secretariat to coordinate activities in conjunction with a scientific advisory committee tasked with facilitating and promoting priority research and training activities Increase awareness of decision-makers, the donor community, technical support agencies and other stakeholders about the burden and costs of NZDs as well as cost-effectively combating them Establish international/regional resource centers for producing, gathering and distributing educational and advocacy materials 3/ Research Ensure research activities integrated with surveillance and control needs Recognize and support centres of excellence in NZDs research linked to local public health and agricultural systems Promote and facilitate pilot studies on the NZDs including burden, socioeconomic costs and risk analysis including adjusting for underreporting 4/ Diagnosis and Surveillance Promote systematic collection and assimilation of data on neglected zoonoses infections in both human and animals Ensure surveillance systems for each NZD established and incorporated in national health and agricultural information systems Develop and manage reporting systems for both veterinary and medical data Use existing databases as appropriate. Reviews of the status of the different NZDs at national/regional/global levels needed Ensure diagnostic facilities for neglected zoonoses available with appropriately trained staff at the regional and national levels as appropriate Validate and standardise diagnostics for NZDs at the regional level 5/ Control Promote cost-effective integrated approach to NZDs within existing health and agricultural systems Formulate and validate integrated control packages to address several related disease/health/livestock problems Conduct operational research to assess impact, safety and cost-effectiveness of NZDs control packages, using disease control and cost modelling exercises where appropriate Target most vulnerable populations - rural smallholders, pastoral communities and urban/peri-urban livestock producers ILRI, Nairobi, 13 15 November 2007 5 Conduct pilot intervention studies based on research indicating the most appropriate, acceptable, cost-effective and sustainable strategies

Integrated Control of Neglected Zoonotic Diseases in Africa 4 Conclusions Control of NZDs is a recent initiative. The concept and branding of integrated surveillance, prevention and control of NZDs was jointly proposed by DFID-AHP and WHO in early 2005. The report of the WHO/DFID-AHP inception meeting on The control of neglected zoonotic diseases: a route to poverty alleviation held at WHO headquarters in September 2005 was very well received internationally and paved the way for subsequent NZD initiatives. Neglected diseases are at the core of human rights as they deal with issues related to poverty, discrimination, stigma and the right to health. WHO Meeting on Intensified Control of Neglected Diseases Berlin, 2004 The meeting on integrated control of NZDs in Africa is satisfied with the progress achieved over the past two years since the initial meeting. The momentum has been maintained until this second meeting, which is tackling some of the practical, institutional, political and resource-related issues associated with the NZD initiative in Africa. Strong international interest in this initiative is evidenced by the support provided for the meeting from international technical support agencies (WHO, FAO, OIE) and research institutes (ILRI, DBL) as well as the European Commission and the African Union. In addition to the commitment of these agencies, institutes and intergovernmental organizations, funding bodies have also begun to recognize the impact of these diseases and have started supporting the development of the concept of NZD prevention and control (e.g. the EU Research Directorate, the Wellcome Trust, the Bill & Melinda Gates Foundation). Recommendations from the meeting for a plan of action to combat NZDs in Africa have been developed following intense deliberations of the diverse group of researchers, programme managers, policy-makers, international scientists and representatives of technical support agencies assembled in Nairobi to consider the best way forward. The results provide the basis for a strategic framework to effectively address the burden of NZDs in Africa. One of the main components of this plan is the establishment of a coordinating body in the form of a scientific advisory committee to provide managerial support and to serve as the driving force for combating NZDs. The meeting also called for an assessment of current NZD surveillance and control activities and tools in Africa with an aim of filling in the gaps through development of regional and national surveillance and control programmes based on proven guidelines and tested strategies. The justification and demand for these activities will be secured through understanding and information about the burden of NZDs on African society and their recognition as a serious hindrance to development. The NZD initiative may benefit from the global attention paid to highly pathogenic avian influenza due to H5N1, whereby new whereby new veterinary public health (VPH) structures and initiatives established to deal with that emerging threat (e.g. OIE/FAO/AU Animal Health Centres, Regional/National Task Forces) can also be utilized to address the persisting problem of endemic NZDs. In addition, a number of neglected tropical diseases (NTDs) are targeted for elimination. The successful completion of these programmes will create new opportunities on the global NTD platform for increased attention to be paid to NZDs that are already being included as a subset of the NTDs under WHO s global plan to combat NTDs (http://whqlibdoc.who.int/hq/2007/who_cds_ NTD_2007.3_eng.pdf). 6 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept 5 Recommendations AT THE GLOBAL LEVEL 1. Establish a WHO Global Scientific Advisory Committee for NZDs in collaboration with FAO and OIE where veterinary and medical fields are represented together with other relevant technical areas. 2. Step up advocacy for NZDs and the one health approach. Participants recommended that WHO along with other relevant organizations (particularly FAO and OIE) take a leading role by bringing NZD prevention and control to the attention of their respective governing bodies. A realistic target date for WHO would be the World Health Assembly in May 2009. The involvement of international organizations not represented at this meeting such as UNICEF was recommended. 3. Increase as an urgent need awareness among decision-makers, the donor community and other stakeholders on the burden of NZDs and their impact on livelihoods, human health and productivity and other associated costs. 4. Consider extending the scope of work to prevention and control of avian influenza and other zoonoses including NZDs of the 3 rd International Ministerial Conference on Avian and Pandemic Influenza (New Delhi, 4 6 December 2007) in an effort to further increase awareness and mobilize much needed resources 1. 5. Make clearer in NTD advocacy documents and on the NTD web site that NZDs also mostly affect populations living in the tropics (as detailed in the WHO Plan to Combat Neglected Tropical Diseases, 2008 2015) 2. 6. Keep up to date and disseminate inventories of vaccines, treatments, public awareness materials, suppliers and supplies related to NZD prevention and control. 7. WHO and partners should plan the next global conference on NZDs (proposed deadline: end of 2009). 1 Action already taken by the EU. A statement endorsed by the 21 members and shared with FAO, OIE and WHO was made during the New Delhi pledging meeting in December 2007. 2 Discussion already held with NTD Director, action taken within WHO. ILRI, Nairobi, 13 15 November 2007 7

Integrated Control of Neglected Zoonotic Diseases in Africa AT THE REGIONAL LEVEL 1. Establish a NZD International Scientific Advisory Committee (NZD - ISAC) This committee should include representation from AFRO, WHO Regional Office for the Eastern Mediterranean (EMRO) and AU (IBAR and human health group as well as other regional institutions. Its main role will be to share and communicate information and provide a model for how the one health approach can be applied in Africa in relation to NZDs in the context of eco-systems that facilitate transmission of NZDs and existing institutional frameworks for their prevention and control. 2. Invite the President of Liberia, Her Excellency Ellen Johnson Sirleaf (or another notable figure from the region) be to be associated with the work of the Scientific Advisory Committee focusing on Africa. 3. AU, FAO, OIE and WHO should coordinate the setting up of a biennial meeting of ministers of agriculture/livestock and health from African states, with a plan to review issues of joint concern regarding NZDs. (This meeting should be modelled on the biennial Inter-American Meeting in Health and Agriculture at Ministerial Level (RIMSA) coordinated by the Pan American Health Organization (PAHO). 4. WHO, FAO, OIE and other organizations or entities such as the AU, EU, World Bank (WB), African Development Bank, ALive, bilateral development agencies and, international foundations should join forces to support and facilitate cooperation, intersectoral collaboration, coordination and resource mobilization by organizing regular regional executive meetings involving ministers of health and agriculture/livestock as well as technical meetings, stimulating (operational) research, and strengthening veterinary/agriculture and health services. 5. Newly established regional FAO/OIE/AU animal health centres should support activities to control NZDs within their regions. 6. WHO with FAO and OIE should lead a regional inventory of existing intersectoral arrangements and ongoing NZD control programmes. 7. WHO AFRO with HQ support should develop a regional strategy and mid-term plan for NZD surveillance, prevention and control. 8. WHO, FAO, OIE and other organizations or entities such as the AU, EU, WB, IFAD and ALive should plan for a next Africa regional meeting on NZDs (suggested deadline: early 2009). 8 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept AT THE NATIONAL LEVEL (WITH GLOBAL AND REGIONAL INPUTS) 1. Clarify the role of national VPH structures in the context of their contribution to health care, while recognizing that the responsibilities of VPH go beyond NZDs. 2. Use guidelines developed by the NZD International Scientific Advisory Committee to guide how VPH units should be established and structured. It will be crucial to be very clear as to whom they report to and where they are located. The mandate of the national intersectoral committees or task forces established to deal with avian influenza should include other zoonoses of public health significance including NZDs. In addition, these committees should become permanent as was successfully accomplished in Ethiopia. 3. Produce and diffuse advocacy and informational material in all media (radio, film, print media, etc.), targeting decision-makers and those who implement and enforce recommendations and, separately, end-users (that is, those people threatened most by NZDs). The first group of briefing documents targeting specific key decision-makers (ministers of agriculture/livestock, finance, health, education and the interior and writers of policy documents) will need to be designed. Developing the educational materials for the second group of documents will require the active involvement of mass media technicians and communication experts. 4. Include zoonoses in the education system (alongside other health and veterinary issues) at all levels from primary school onwards and integrate NZDs in the health delivery system. 5. Include NZDs in the curricula of veterinarians and physicians, with the possibility of joint courses at undergraduate and postgraduate levels. 6. Promote synergy through reciprocal dialogue between employers and educational institutes so that employers (e.g. ministries) advise educational establishments on the profiles required for effective NZD control. 7. Conduct pilot studies on the burden of NZDs and their societal costs, risk analysis and adjusting for underreporting. In particular, conduct cost analyses of incentive-based research and intervention packages, and study the relationship between poverty, human health-related risks, livestock production, distribution systems and value chains (farm to fork, stable to table) and NZDs. 8. Conduct an inventory of notifiable NZDs (in humans and animals) in each country, evaluate and develop diagnostic tools (including molecular tools) and conduct knowledge, attitude and practices (KAP) studies in local settings. Improve the compatibility of reporting systems for human NZDs and animal NZDs. 9. Initiate pilot studies to test the acceptability, effectiveness, timing and costing of possible combined integrated prevention and control packages. In this respect, WHO and its partners should produce guidelines for the development and delivery of such packages. Increased public awareness of all relevant audiences is a crucial and cross-cutting component of any integrated package. ILRI, Nairobi, 13 15 November 2007 9

Integrated Control of Neglected Zoonotic Diseases in Africa 6 Management and Advocacy The Cysticercosis Working Group in Eastern and Southern Africa (CWGESA), a registered NGO, was established in 2002 to facilitate integrated research and control activities to combat cysticercosis CWGESA Responsibilities of VPH Units go beyond simple meat inspection and food safety issues to include active surveillance and awareness creation, with reference to existing guidelines and in response to previous/recent developments. KEY ISSUES CONSIDERED Management 1. Need for an international entity with strong regional representation to steer the Integrated Control of Neglected Zoonoses initiative, with particular attention to Africa. 2. This initiative requires: an intersectoral approach; effective communication among all stakeholders; the establishment of and liaison with regional NZD networks, collaborating and reference or training centres and other relevant public and private institutions including academia. Advocacy 3. Need for Regional Scientific and Technical Advisory Groups to advise the above entity in planning, implementing and monitoring control and research activities in order to: conduct an inventory of current research into epidemiology, burdens and control of NZDs; identify significant research gaps in these areas; ensure that research efforts are integrated with control needs. 4. Need to mobilize human and financial resources by securing the commitment of governments, international and regional organizations and donor bodies to enable operational research, training and implementation of surveillance and control activities. 1. Establish regional resource centres for gathering educational and advocacy materials on NZDs in collaboration with WHO, FAO and OIE. 10 2. Increase awareness among decision-makers and policy-makers, donor community and other stakeholders about the burden, impact and costs of NZDs. ILRI, Nairobi, 13 15 November 2007 3. Disseminate and improve availability of information on all aspects of NZDs.

Applying the One Health Concept MAIN DISCUSSION POINTS Establishing an International NZD Scientific Advisory Committee and VPH Units An international scientific advisory committee for NZDs (NZD- ISAC) should be established to facilitate information-sharing. Both veterinary and medical fields must be represented on the committee, while recognizing the need to involve other professionals such as scientists, economists and sociologists. As Africa is a key area for NZDs, the NZD-ISAC should include representation from AFRO, and include AU (IBAR and human health group). The committee should also involve existing vertical groups (e.g. African rabies group, CWGESA, Bovine tuberculosis (TB) network), which could include setting up a forum for regular meetings with representatives from these groups. A time-line should be fixed for the basics of setting up the NZD- ISAC, ideally before the next global neglected zoonoses meeting. NZD-ISAC should be responsible for setting dates and themes for future international and regional NZD meetings, which should be held regularly, probably at least every two years. The NZD-ISAC should provide a model for how the one health approach can be applied in Africa in relation to NZDs in the context of the eco-systems facilitating their transmission. This should initially be interpreted in terms of a dynamic intersectoral approach to the control of these diseases. The NZD-ISAC should establish ad hoc committees to address the following as required: management and advocacy; research and capacity building; diagnostics and surveillance; prevention and control. The NZD-ISAC should identify existing national, regional and international centres where NZD information could be compiled, stored, updated, accessed and disseminated (i.e. NZD reference centres). The NZD-ISAC should clarify the role of national VPH structures in the context of their contribution to health care, while recognizing that the responsibilities of VPH go beyond just the NZDs. The NZD-ISAC should provide guidelines on how national VPH units should be established and structured. Reporting arrangements should make clear to whom and in which location the units should report (ministry of health versus ministry of agriculture/livestock). ILRI, Nairobi, 13 15 November 2007 11

Integrated Control of Neglected Zoonotic Diseases in Africa Effective advocacy based on evidence of the burden of NZDs on endemic communities is needed to ensure that the importance of NZDs is recognised by decision-makers and donors. Establishing VPH Units There is a need to institutionalize a national inter-ministerial committee in order to oversee the VPH units, both to clarify financial and authority issues. This should be advocated for at the policy level of national strategic action plans (as was successfully demonstrated in Ethiopia for avian influenza and the potential to transform these units to deal with more zoonoses). VPH units should oversee any programme or projects on NZD research, surveillance, and prevention and control and advise the leading organization of each programme/project. Responsibilities of VPH units go beyond simple meat inspection and food safety issues to include active surveillance and awareness creation, with reference to existing guidelines, and should be responsive to developments. Activities with respect to NZD should be included in the routine work of VPH units. Affected countries should identify the key NZDs and assign appropriate tasks for their surveillance, prevention and control to the VPH unit. Staffing of VPH units should reflect professional balance and appropriate training. Reporting structures should be promote links with the veterinary/ livestock, agriculture and health services and research organizations. Awareness creation among decision-makers There is an urgent need to increase awareness among decisionmakers, the donor community and other stakeholders on the burden, impact on livelihoods, human health, agricultural production and other costs imposed by NZDs. This task will rely on the work on surveillance, estimation of incidence and prevalence and calculation of disease burden. Information on the total costs to society of NZDs (in both people and their livestock) can be used to demonstrate that controlling NZDs is highly cost-effective. Information used should be highly relevant to the countries/organizations/groupings being targeted, and also appropriately packaged. The one health concept should be further explained and promoted. Active targeted lobbying for NZD control (e.g. for tabling items on World Health Assembly agenda, FAO council, AU council of Heads of State) by briefing relevant national ministers should be undertaken by key members of the NZ-ISAC or similarly highprofile individuals. AU, WHO and FAO should initiate a biennial meeting of Ministers of Agriculture/Livestock and Health from African states, with a view to reviewing issues of joint concern. (This should be modelled on the biennial RIMSA meeting organized in Latin America coordinated by PAHO.) 12 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept Opportunities for regular interaction among individuals at all these levels (meetings, workshops, seminars, briefing sessions) should be created. Advocacy and information materials in all media (radio, film, print) should be produced and diffused, in particular, briefing documents targeting specific key decision-makers and policy-makers (Ministers of Agriculture, Finance, Health, writers of policy documents). Mass media technicians and communication experts should be actively involved in this process. New discoveries, innovations and research breakthroughs of relevance to the NZD control should be communicated to decisionmakers. NZD issues should be included in the education system (alongside other health and veterinary issues) at all levels from primary school onwards. Synergies should be promoted through reciprocal dialogue between employers and educational institutes so that employers (e.g. ministries) can advise educational establishments on the profiles required for effective NZD control. Control of NZDs should be integrated into the health-care delivery systems for both humans and animals. Decision-makers and policy-makers should be identified at different levels (see list of acronyms page 40 41): Sub-national Local/district/cercle authorities State/province authorities/government NGOs Other stakeholders (e.g. civil society organizations; CSOs) A forum of existing groups with a vertical approach to controlling NZDs (e.g. CWGESA, African Rabies group, Bovine TB network, etc) need to be consulted continuously through regular meetings of representatives. National relevant arms of government (parliaments, office of the president) ministries/departments/sectors (especially Ministry of Finance, authors of Poverty Reduction Strategy Papers (PRSPS), policy dialogues) NGOs, CSOs Private sector Professional organisations Producers associations Educational institutions Regional and Sub-Regional AU African Development Bank Regional economic alliances (e.g, CEAC, EAC, ECOWAS, IGAD, SADC, UEMOA, UMA, etc.) Regional/Subregional Research Organizations (AMREF, FARA, ASARECA, CORAF-WECARD, SADC-FANR, AARINENA, etc.) ILRI, Nairobi, 13 15 November 2007 13

Integrated Control of Neglected Zoonotic Diseases in Africa International organizations United Nations agencies (e.g. WHO, FAO, UNICEF, IFAD, IAEA, UNEP, UNESCO, UNDP) World Bank IMF International Research Organisations (e.g. CGIAR centres, GFAR) International NGOs OIE European Union Bilateral donor organisations National organisations with an international mandate Global foundations and trusts NZD Resource Reference Centres Resource or information centres at national and regional levels are needed to make available appropriate information on NZDs at all levels and to all stakeholders. To avoid duplication of medical/veterinary resource centres, consideration should be given to creating NZD sections within existing centres or independent NZD resource centres as appropriate. Good management of these resource centres is imperative: for example, it is vital that information materials are submitted to these centres in a timely manner; ways and means to increase access to NZD resource centres should be devised and those who need the materials should be alerted to their availability (e.g. e-mail alerts) The relevant VPH unit should take the lead in ensuring the NZD resource reference centre is established and the information effectively disseminated. Pastoralist boy near Lake Chad. Consumption of unpasteurized milk enables transmission of NZDs from livestock to humans. Markus Hilty/STI 14 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept Programmes for sustained personal interchange between ministries of agriculture and ministries of health should be developed, to facilitate long-term communication, collaboration and programme development across the sectors. WHO Consultation on Emerging Zoonoses, 2004 ACTION PLAN 1. WHO to establish an International Scientific Advisory Committee for NZDs (NZD -ISAC) in collaboration with FAO and OIE a. There should be diverse representation on the committee with regard to disciplines, geography, gender, etc. b. Africa should be represented scientifically as well as politically with a representative of the AU. c. Terms of reference for the Committee should be formulated. d. The committee will assist WHO and other organizations and agencies with organizing international and regional NZD meetings. The next international and Africa meetings should be held in 2009. e. Ad hoc subcommittees on management and advocacy, research and capacity building, diagnostics and surveillance, and prevention and control will be formed. f. Guidelines concerning the structure and functions of regional and national VPH units will be developed by the above Committee. g. Guidelines for establishing national, regional and international reference centres for NZDs will be developed and the Committee shall nominate existing institutes to serve as hosts for the NZD reference sections. 2. Establish/strengthen national Veterinary Public Health Units a. An inventory of African countries where VPH units exist will be conducted by the NZD-ISAC. b. VPH units will be established in countries where they do not already exist and strengthened in those where they do exist based on general guidelines provided by the NZD-ISAC: i. National interministry committees will be formed to oversee the VPH units; ii. The structure and functions of the VPH unit and its location will be determined by the interministry VPH committee. 3. Increase Awareness of Decision-Makers a. The NZD-ISAC will lobby to have the issue of NZD control addressed by the governing bodies of AU, WHO, FAO and OIE. A lot of people who really need informational materials on NZDs currently find them inaccessible. Alexandra Shaw b. The NZD-ISAC, AU, WHO, FAO, OIE and other relevant bodies will initiate joint regional meetings of the Ministers of Health and Agriculture/Livestock on a regular basis (biennial) to review the NZD situation and other issues of joint concern. ILRI, Nairobi, 13 15 November 2007 15

Integrated Control of Neglected Zoonotic Diseases in Africa c. The NZD-ISAC together with WHO, FAO, OIE and AU will assist regional NZD networks/working groups to produce advocacy and informational material on the societal costs and benefits of controlling NZDs for dissemination to decision-makers at all levels. d. The VPH units and regional NZD working groups/networks with support from NZD-ISAC will actively lobby national and regional governing bodies to include the issue of NZDs in the health, agriculture/livestock and educational systems. 4. Establish Regional/National NZD Reference Centres a. NZD centres should be established by the VPH units within national veterinary or medical resource centres or as independent NZD reference centres when appropriate b. AU-IBAR/FAO/OIE regional animal health centres should select national NZD units to serve as regional reference centres for Africa. c. Mechanisms for timely submission and dissemination of information should be instituted (e.g. Africa VPH network, national/regional e-mail notification systems). d. VPH units should manage the NZD reference centres (whether national or regional in scope) i. Hiring an administrator ii. Establishing a NZD office iii. Liaising with networks/working groups and vertical programmes for individual diseases to share information Butcher in Mozambique. Some of the NZDs are transmitted to humans through meat. Geraldo Dias 16 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept 7 Research and Capacity Building KEY ISSUES CONSIDERED Research 1. An inventory of ongoing and new research on the epidemiology, burdens and control of NZDs in Africa should be compiled and maintained and research gaps in these areas in relation to control needs should be identified. 2. A standardized and accepted methodology for quantifying the burdens and costs of NZDs in Africa should be developed. 3. Support centres of excellence in NZD research linked to local public health and agricultural systems should be identified. 4. Pilot studies on the NZDs, especially in regard to their burden and socioeconomic costs, and risk analysis including adjusting for underreporting should be conducted. Capacity Building 1. Regional training centres on NZDs should be established. 2. Individual scientists, medical doctors, veterinarians, animal scientists and other appropriate personnel should be trained in techniques applicable to the diagnosis, epidemiology, burdens and control of NZDs should be trained. Epidemiological studies are needed to demonstrate the existence of and links between the NZDs in both animals and man, to support advocacy and assist with designing control strategies 3. Training packages on prevention and control of NZDs should be provided to target groups in affected communities (e.g. livestock keepers) with particular regard to the importance of the role of women through health education and agricultural extension. MAIN DISCUSSION POINTS The term training should be substituted with capacity building. Research should guide control. Both basic and operational research are needed. Emphasis should be placed on bridging research and development. Research should be aimed at improving livestock marketing opportunities and livelihoods of farmers/livestock keepers. Involvement of stakeholders is important especially for sustainability (e.g. validating endemic community acceptance of intervention tools). ILRI, Nairobi, 13 15 November 2007 17

Integrated Control of Neglected Zoonotic Diseases in Africa Sustainability can also be ensured by mobilizing affected communities to make change through community and incentivesbased control packages. The research package needs to be attractive to the private sector. Curricula need to be flexible enough to include other sectors. There is a need to ensure publication, dissemination and feedback to study populations of results. It should be remembered to elucidate traditional methods for prevention and control of NZDs. Research and capacity building should be: designed with the aim of achieving cost-effective, ethical and sustainable control or elimination/eradication of NZDs; multidisciplinary, multidisease, intersectoral and interprogrammatic in nature; directed at both humans and animals; contribute to the surveillance and control of NZDs; support diagnostic methods for NZDs; provide evidence on the burden of NZDs based on published and informed data: and promote an incentives-based approach. Research and capacity strategies should: build the capacity of both veterinary and human medical communities as well as of health and agricultural extension workers; identify and strengthen NZD networks and reference laboratories; use existing services in a combined way to share resources; investigate the effectiveness and appropriateness of diagnostic tools and intervention measures (e.g. vaccines). Importance and changeability of predisposing, reinforcing, and enabling factors for control of NZDs at community level need to be investigated to devise appropriate, acceptable and sustainable strategies. Helena Ngowi ACTION PLAN 1. Integrate research activities with control needs a. An inventory of notifiable NZDs (veterinary and human) for each country should be conducted. b. Available data should be gathered and analysed. c. Research gaps should be assessed. d. Diagnostic tools (including molecular tools) should be developed and evaluated. e. KAP and other sociological/anthropological studies should be carried out in local settings. f. Publication and dissemination of local results and feedback to studied communities should be encouraged. 18 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept 2. Establish Centres of Excellence a. Centres that can conduct diagnosis for different NZDs should be identified. b. South South and North South collaboration to ensure training in NZDs should be promoted. c. An inventory of existing networks on specific NZDs should be made. d. Existing networks to promote multidisciplinary, multidisease, multiprogramme and intersectoral collaboration should be linked with each other. e. Multidisease curricula on NZDs at graduate level and in medical and veterinary study programmes should be developed. 3. Conduct pilot studies a. On the burden and societal costs by: i. standardizing data gathering; ii. designing appropriate epidemiological data collection methods; iii. measuring mortality/morbidity/social impact associated with NZDs; iv. conducting farmer field schools on selected issues; v. developing rapid appraisal for proxies of diseases; vi. performing cost analyses of incentive-based intervention packages ; vii. conducting epidemiological studies to demonstrate the existence of and links between the NZDs in both animals and humans. Training local health and agricultural extension workers about NZDs along with other livestock diseases and public health problems. Geraldo Dias ILRI, Nairobi, 13 15 November 2007 19

Integrated Control of Neglected Zoonotic Diseases in Africa We need to conduct NZD burden analyses because it helps with decision making - enabling comparison between the gains from intervention against the costs of the disease. DALYS were developed to obtain a common measure of health for: International comparison Quantify the burden of disease and injuries Determine the global and regional burden of diseases Hélène Carabin b. On Risk analysis by: i. developing transmission dynamic models to link human and animal disease; ii. assessing the relationship between risk, poverty and NZDs; iii. assessing risks of livestock production and distribution systems in relation to NZDs; iv. assessing risks associated with value chains (farm to fork, stable to table). c. On underreporting by: i. developing and validating methods to estimate reporting proportions (biases) at all steps; ii. promoting better linkage with extension services. 4. Develop and validate diagnostic and control tools a. Multi-disease diagnostics that could be used for NZDs should be developed and tested. b. Training packages for field diagnostic tools should be developed. c. District health and agricultural workers should be trained in research methodologies including data collection and record keeping. d. Inclusion of NZDs in existing reporting systems should be promoted. e. Incentive-based control packages for multiple-diseases should be developed and tested. f. Proof of principles for the effectiveness of NZD control in animals for prevention of human disease should be demonstrated. g. Proof of principle studies to show effectiveness of production system changes should be carried out. h. Control measures should be developed and their effectiveness and appropriateness in the field be estimated. 5. Areas for research that could facilitate NZD prevention and control in Africa include: Brucellosis vaccine (RB51) for cattle Improved brucellosis vaccines for small ruminants Treatment and vaccine development against porcine cysticercosis Low cost delivery solutions for administering praziquantel (e.g. injectable or bait formulation) Further development and testing of the echinococcosis vaccine for small ruminants in Africa 20 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept Low-cost vaccine delivery systems (e.g. oral delivery of vaccines) Investigate combined vaccine formulations Cold chain solutions Development of pen-side/field tests (e.g. cysticercosis, echinococcosis, brucellosis) Development of an effective canine leishmaniasis treatment Improved rift valley fever (RVF) vaccine Other operational research to facilitate delivery of interventions including on public awareness. Building capacity for local data management and analysis. through regional training programmes Henry Madsen ILRI, Nairobi, 13 15 November 2007 21

Integrated Control of Neglected Zoonotic Diseases in Africa 8 Diagnostics and Surveillance HAT control programmes have focussed on active case detection involving medical teams conducting surveys at community level. KEY ISSUES CONSIDERED Diagnostics 1. An inventory of currently available diagnostic tools for each of the NZDs required 2. A detailed assessment of gaps in the diagnostic tools available. should be conducted Pierre Virot/WHIB The underpinning for both successful advocacy and for targeting and planning control activities is disease surveillance, based on effective diagnostics 3. The development of new and improved practical tools as appropriate. should be facilitated 4. Diagnostic tools in the African context should be validated and standardized. 5. Availability of diagnostic facilities at the regional (i.e. regional reference centres) and national levels as appropriate should be ascertained. Surveillance 1. Reporting systems (appropriate/innovative) for both agricultural and health data related to NZDs (e.g. clinical surveillance, slaughterhouse surveillance, community-based epidemiological assessment) should be developed 2. Core indicators should be standardized. 22 ILRI, Nairobi, 13 15 November 2007 3. NZD reporting should be integrated into Health and Agriculture Information Systems.

Applying the One Health Concept MAIN DISCUSSION POINTS A surveillance programme for NZDs in Africa should promote systematic collection and assimilation of data on both humans and animals. Surveillance systems should cover each of the NZDs. Existing databases should be used as appropriate, although it is not always clear where data are currently available (ministries, NGOs, etc), Data collection is most often the legal mandate of the respective ministries. Whatever parallel structure (if that is appropriate) is recommended it will have to fit into these systems; The impact of decentralization and privatization on data availability has not always been positive. Data transfer from local to central level (and back again) is often lacking. Medical and veterinary data collection is usually not coordinated and often maintained separately. There are examples of integrated surveillance systems (which currently do not have a focus on zoonoses) through the INDEPTH Network (www.indepth-network. org) which has Demographic Surveillance System (DSS) sites in different countries around the globe. This model is one of those available for collecting data, but may not be appropriate for countrywide, national/local data collection. There is a need for consistent, reliable data at a national level (over a longer term) but also the need for reliable data to demonstrate the neglected status of the diseases in the shorter term. This is necessary to raise the profile of NZDs and ensure adequate longer term resources for control. An example of a regional data capturing system is the East African Disease Surveillance System (EADSS) which depends on effective communication between veterinary and medical partners at each level (district, region, national, regional). Regional collaboration cannot be expected to work if there is no collaboration at the lower levels, to cross-check and validate the data. Data collection implies data storage. Best data storage methods need to be identified. The lack of diagnostic facilities and central/referral laboratories compounds the problem. There is a need for an inventory of national and regional laboratory capacity and data availability. Regional reference laboratories for diagnosis of NZDs should be established to provide services for countries where national diagnostic capacity is not currently available. An example of an established regional reference lab in Africa that could serve as a model is the CWGESA Regional Reference Laboratory for Immunodiagnosis of Taenia solium infections based at the Samora Machel School of Veterinary Medicine, University of Zambia in Lusaka: ILRI, Nairobi, 13 15 November 2007 23

Integrated Control of Neglected Zoonotic Diseases in Africa Local level registration and reporting systems for NZDs containing both veterinary and medical data should be developed. the reference laboratory aims at standardizing immunological screening for T. solium infections in the eastern and southern Africa region; it has capacity for antigen testing for both human and pig serum samples and is building capacity for antibody detection as well; it conducts the same tests using the same reagents and methodology; it uses the same personnel conducting the tests. In many instances the scientists conducting the surveys go to Lusaka with their samples to conduct the testing themselves under close supervision of the reference laboratory technicians and managers; the end result is that results from around the region can be compared easily. So far, nearly 8000 samples have been tested (90% pig samples/10% human samples); charges for testing cover the costs of reagents and other supplies (i.e. non-profit); A five-point flexible scheme could be used to develop a national/ regional NZDs surveillance programme by answering these questions: Which zoonoses are problems in which countries or regions? Which primary data are important, and do veterinarians or medical doctors have a better opportunity for collecting the data for each NZD of importance? What reporting system, if any, is already in place and does it need upgrading? Is diagnostic confirmation available incountry? Regionally? What level of cross-checking is needed and at which level? Can we have combined teams for active surveillance? How can the detailed data be shared with higher levels? Diagnostics research and development for NZDs should be focused on developing tests that are practical and inexpensive, can be stored easily and provide rapid results. There is no one size fits all method for improving data collection for these neglected diseases. Each country and each situation (e.g. a disease focus) needs to be considered individually. ACTION PLAN An independent validation of NZD diagnostic tests is required (i.e. those who have developed the tests should not be the ones validating them). To conduct (in parallel) demonstration surveillance projects on NZDs in selected African countries. Steps are as follow: 1. Form national multidisciplinary teams to conduct active surveys on the burden of NZDs relevant for each selected country 2. Identify key individuals from the medical and veterinary services at the country level to serve as national NZD Focal Points responsible for coordinating the surveillance project jointly including collation and cross-checking data 3. Assess capacity of national Health and Agriculture Information systems concerning how they address NZDs and relevant data will be collated from the different ministries and official bodies to form an initial NZD database 24 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept a. Veterinary Services i. System for data collection and reporting slaughterhouses public/private/ngo sector veterinary laboratories/ diagnostic facilities decentralized veterinary field service (local, district, national) university sector ii. Trained professional personnel iii. Established veterinary extension services infrastructure b. Medical Services i. System for data collection and reporting Public/private/NGO sector medical laboratories/ diagnostic facilities Public and private health centre and hospital records University sector ii. Trained professional personnel iii. Established veterinary extension services infrastructure c. Level of under-diagnosis and under-reporting to be assessed d. Critical components of the existing diagnosis and reporting system that are in need of support and improvement will be identified. 4. Conduct large-scale community-based surveys for NZDs using the most appropriate diagnostic tests: Surveys should be conducted in multiple sites to fully represent different agro-ecological zones and livestock production systems a. Multidisciplinary mobile survey teams should collaborate with existing resources/networks, infrastructure and both health and agricultural extension services. b. Opportunities for addressing other adverse human and animal health/production conditions suffered by the surveyed communities while collecting the core data should be facilitated to promote the one health approach. FTA (Flinders Technologies Australia ) cards have been found to be an inexpensive and practical way of collecting and storing blood for diagnosis of trypanosomiasis. Blood taken from a cow s ear vein is applied to a card and later tested with polymerase chain reaction (PCR) for detection of trypanosome species ILRI, Nairobi, 13 15 November 2007 25 Sue Welburn

Integrated Control of Neglected Zoonotic Diseases in Africa 9 Prevention and Control Proper meat inspection and control including responsible disposal of infected carcasses and visecera can help combat NZDs. KEY ISSUES CONSIDERED Prevention and Control 1. Integrated, cost-effective control packages for NZDs should be developed based on a best bet strategy of recognizing the tools and resources actually available as well as what is appropriate, acceptable and sustainable for the targeted communities. Pierre Virot/WHIB Public awareness and demand for action is a crucial entry point for prevention and control for NZDs. Policy-makers also have an important role to play with regard to advocating on the behalf of the need for prevention and control of NZDs to their ministers. 2. Strategies should take into account the economic, sociological and cultural aspects related to the diseases as well as traditional knowledge. 3. The proof of principle for integrated control should be demonstrated through pilot projects, which should assess the impact, safety and cost-effectiveness of the strategies. 4. Cost-effective single NZD control programmes that promote an intersectoral approach should be supported where appropriate. 5. Efforts should be directed primarily at rural smallholder and pastoral communities as well as marginalized urban/periurban livestock producers. 26 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept MAIN DISCUSSION POINTS Specific risk groups for the different NZDs and beneficiaries of interventions should be identified. The most vulnerable populations at risk of NZD infection are livestock keepers, veterinarians and animal health workers, laboratory workers, consumers, children and women. Operational research needs include intervention delivery systems and the benefit of combining interventions. Leishmaniasis and RVF should be considered for inclusion in the NZD group of diseases for Africa (RVF classified as an emerging zoonosis). VPH units should be created/strengthened and entrusted with managing/coordinating national NZD prevention and control efforts. Experience indicates that basing VPH units in the Ministry of Health to be the most effective arrangement. The formation at national level of an inter-ministerial committee with task forces to address NZDs could greatly facilitate prevention and control. It would be helpful to involve other relevant ministries in addition to those of health and agriculture/livestock such as Ministries of Finance, Wildlife and Tourism. In countries where a highly pathogenic avian influenza virus (HPAI) task force exists, its mandate could be expanded to neglected and other zoonotic diseases. Involving Ministries of Finance would be strategic with regard to mobilisation of resources aimed at NZD prevention and control. The newly established regional FAO/OIE/AU-IBAR animal health centres should include support of NZD activities within their regional mandate and facilitate the national VPH units. There is a need for testing approaches that combine vaccination programmes for animals and children in pilot studies to investigate their acceptability, effectiveness and costing. Policy-makers should advocate with their respective ministers to raise the issue of the burden and need to control NZDs on the agenda of the meetings of the governing bodies of relevant regional and international organizations (e.g. AU, World Health Assembly, FAO Conference and OIE chief veterinary officers (CVOs) annual meeting). International specialized (WHO, FAO, OIE) and other organisations/entities (e.g. AU, EU, WB, ALive) should join forces and play supporting and facilitating roles for cooperation, coordination and resource mobilization aimed at NZD prevention and control in Africa and elsewhere (e.g. arranging a regular regional meeting involving Ministers of Health and Agriculture/Livestock, technical meetings, stimulating (operational) research, strengthening veterinary and heath services, etc). ILRI, Nairobi, 13 15 November 2007 27

Integrated Control of Neglected Zoonotic Diseases in Africa There is a strong need for visibility and advocacy for NZDs as public awareness (and especially consumer demand) is a crucial entry point for prevention and control of NZDs. Regional inventories of vaccines, treatments, public awareness material, suppliers and supplies relevant for NZD prevention and control should be conducted, updated on a regular basis and reported to the appropriate bodies. Means for prevention and control of NZDs should be made accessible in Africa. Vaccination campaigns for NZDs may serve as an entry point for other interventions such as health education. The appropriateness of combining animal vaccination programmes with that of children should be considered and guidelines for such developed: NZD research should be integrated with NZD prevention and control needs. With regard to the benefits of prevention and control of the NZDs, it is helpful to consider the following with respect to each of the NZDs: animal species affected human risk groups preventive, curative and control measures available (or desirable) beneficiary groups possible added value for the intervention(s). The integrated approach to preventiona and control of NZDs can be extended to incorporate non-zoonotic public health and livestock problems prevalent in the same impoverished communities. Different modalities of integrated control packages: combined vaccines against different zoonotic and/or nonzoonotic diseases (e.g. anthrax and blackquarter vaccines for cattle); combining different types of interventions for the same species of animal (e.g. rabies vaccination and praziquantel administration to dogs); Combined interventions for different animal species (e.g. vaccination of cattle and dogs). Lessons can be learnt from current ongoing integrated zoonoses control programmes such as sleeping sickness (SOS) and RVF. ACTION PLAN 1. Conduct, maintain and report inventories of control activities and tools a. Make an inventory of existing intersectoral arrangements and ongoing zoonoses control programmes. b. Define the status and needs regarding vaccines, treatments, diagnostics, public awareness material, suppliers and supplies for surveillance, prevention and control of NZDs. 28 ILRI, Nairobi, 13 15 November 2007

Applying the One Health Concept 2. Develop guidelines for implementing NZDs prevention and control activities a. Develop regional strategies and midterm plans for NZD prevention and control in the Africa region in collaboration with WHO, FAO and AU. b. Develop and deliver integrated NZDs control and prevention packages (including components on public awareness). 3. Initiate pilot studies to test the acceptability, effectiveness, timing and costing of possible combined integrated prevention and control packages for NZDs 4. Secure agreement from the OIE/FAO/AU regional animal health centres in Africa to include combating NZDs as part of their mandate 5. Develop and implement a plan for raising the issue of prevention and control of NZDs at the governing body meetings of the WHO, FAO, OIE and AU Sarah Cleaveland Mass vaccination campaign of dogs in Tanzania ILRI, Nairobi, 13 15 November 2007 29